Unplanned visits and midwife-led antenatal care.

INTRODUCTION: Midwives provide antenatal care to women to ensure the health of both mother and baby, according to women's needs. This study aims to investigate demographic and social, clinical and obstetrical factors that may be associated with unplanned visits to the emergency by nulliparous and multiparous women who received midwifery care during the antenatal period. METHODS: This was a retrospective cohort study with data collection from medical records of the CHU Saint-Pierre hospital. A total of 971 women gave birth between 1 January and 31 December 2017 and received midwifery-led care during their pregnancy. Descriptive statistics and multivariable logistic regression models with 95% confidence intervals (95% CI) were performed separately for nulliparous and multiparous women. RESULTS: For nulliparae (n=246), the odds of visiting emergency services during pregnancy were 1.45 times (95% CI: 1.08-2.27) higher in women with more previous pregnancies than women with less previous pregnancies, 3.57 times (95% CI: 1.43-11.11) more likely in women without than with high-level hypertension, and 1.09 times (95% CI: 1.01-1.25) more likely in women with less previous midwifery-led visits than women with more previous midwifery-led visits. For multiparae (n=444), the odds of visiting emergency services during pregnancy were 2.12 times (95% CI: 1.06-6.07) higher in women presenting risk factors at first consultation than women without such factors. CONCLUSIONS: For nulliparous and multiparous women, some characteristics seem to be associated with unplanned visits. Spontaneous visits may be driven by a need for care perceived by women and/or their partner but not specifically by urgent or unfavorable medical conditions.

First trimester ultrasound prediction of velamentous cord insertions: a prospective study.

INTRODUCTION: The marginal and velamentous cord insertions complicate around 8% of pregnancies and are at higher risk of adverse perinatal outcomes. Their visualisation seems to decrease with advancing gestational age. Our aim was to analyse whether an umbilical cord insertion in the lower third of the uterus during the first trimester could predict abnormal cord insertions later in pregnancy. METHODS: This was a prospective multicentre study in two hospitals. During the first trimester, the cord insertions were inspected as well as their location (lower third of the uterus or not). Finally, all cord insertions were described at delivery. RESULTS: During the study period the cord insertion was described in 1620 patients of which 87.7% had a normal cord insertion, 11.9% (n = 192) a low cord insertion, and in 3.8% the insertion could not be situated. We find that 4.7% of those who have a low-lying cord insertion versus 0.7% in the normal cord insertion group during the first trimester will have a velamentous cord insertion subsequently (OR = 6.67; 95% CI = 2.67-16.63). CONCLUSION: The detection of a low lying umbilical cord insertion during the first-trimester ultrasound can help to predict an abnormal cord insertion at delivery particularly a velamentous cord insertion.

Do recent immigrants have similar obstetrical care and perinatal complications as long-term residents? A retrospective exploratory cohort study in Brussels.

PURPOSE: Recent immigrants (RIs) face various barriers affecting quality of care. The main research question assessed whether perinatal complications (during pregnancy, labour, delivery and neonatal period) were similar in RIs to those in long-term residents (LTRs). The secondary question assessed whether prenatal and perinatal care was similar in the two groups. METHODS: This is a monocentric observational study, carried out in Brussels between November 2016 and March 2017 (n=1365). We surveyed 892 pregnant women during prenatal consultations and immediate postpartum period in order to identify RIs of less than 3 years (n=230, 25%) and compared them with LTRs (n=662). Sociodemographic data, baseline health status, prenatal care, obstetrical and neonatal complications were compared between these two groups. Multivariable binary logistic regression was conducted to examine the occurrence of perinatal complications (during pregnancy, labour and delivery, and neonatal period) between RIs and LTRs after adjustment for potential confounders. RESULTS: RIs were living more frequently in precarious conditions. RIs were younger (p<0.001) and had a lower body mass index (p<0.001) than LTRs. Prenatal care was often delayed in RIs, resulting in fewer evaluations during the first trimester (p<0.001). They had a lower prevalence of gestational diabetes mellitus (p<0.05) and less complications during the pregnancy even after adjustment for confounding factors. Similar obstetrical care during labour and delivery occurred. After adjustment for confounding factors, no differences in labour and delivery complications were observed. Although RIs' newborns had a lower umbilical cord blood pH (<0.05), a lower 1 min of life Apgar score (p<0.01) and more frequently required respiratory assistance (p<0.05), no differences in the composite endpoint of neonatal complications were observed. No increase in complications in the RI group was detected whatever the considered period. CONCLUSION: RIs had less optimal prenatal care but this did not result in more obstetrical and perinatal complications.

Urgent Medical Aid and Associated Obstetric Mortality in Belgium.

Most Belgian citizens are covered by comprehensive medical insurance (AMI). Due to recent and significant undocumented immigration, an increasing number of patients have no health coverage. They may, however, qualify for "Urgent Medical Aid" (AMU). Still, some patients have no health insurance of any kind (no coverage). This study, conducted in a hospital which cares for a large number of undocumented immigrants, looked at the proportion of women benefiting from either "AMI" or "AMU" and those who have "No coverage" and addressed obstetrical outcomes in each of the three groups. Design: retrospective observational study. We collected data of all singleton pregnancies and deliveries from the CHU St Pierre maternity ward, between 1.10.2015 and 31.3.2016. Women were classified, prospectively, by our social workers, as having access to AMI, AMU or having "No coverage". Demographic, obstetrical and perinatal data were systematically collected and validated on a day-to-day basis and comparisons were then made between the three groups of women. During the follow up period, 1.439 women had access to regular social security (AMI) (87%), 142 women (10%) to AMU and 38 (3%) had no coverage. Women who benefited from AMU were younger and their first prenatal consultation occurred later in the pregnancy than it did for women with AMI. There were no significant differences in obstetrical outcomes between the three groups of women. Urgent medical aid (AMU) confers a certain normalisation of obstetrical care to pregnant women who would otherwise have no access to health care coverage.

Cervical, anal and oral human papillomavirus (HPV) infection in young women: A case control study between women with perinatally HIV infection and women with non-perinatally HIV infection.

OBJECTIVES: HPV infection may differ in women who are HIV-positive since birth (perinatally infected, P-HIV) and those who acquire HIV later in life (non-perinatally infected, NP-HIV). We assessed the HPV prevalence in relation to the HIV acquisition route and HPV vaccination status. STUDY DESIGN: Case control study comparing 22 P-HIV with 22 NP-HIV patients. Cervical, anal and oral specimen were collected for HPV PCRs. The primary outcome was the prevalence of cervical, oral and anal HPV in P-HIV and NP-HIV patients. The secondary outcome was to identify risk factors for HPV infection. Comparative statistics for two independent groups, univariate and multivariable logistic regression analyses were used. RESULTS: There were no differences between perinatally and non-perinatally infected women. Cervical dysplasia was found in 12/44 (27 %) patients and high-risk HPV (hrHPV) in 30 % of cervical (of which 89 % were hrHPV other than 16 and 18), in 3 % of oral and 65 % of anal specimens. All woman were using combined antiretroviral therapy (cART) and 64 % had HIVRNA < 20 cp/ml. A CD4 count <350/mm³ was associated with cytological abnormalities (OR: 13.52, p = 0.002) and with cervical HPV (OR: 6.11; p = 0.04); anal HPV was associated with a previous cervical dysplasia and concomitant cervical HPV infection. None of thirteen vaccinated patients had a 6/11/16/18 HPV infection. CONCLUSION: In this small series of women under cART, we did not observe a difference in HPV infection in relation to the route of HIV acquisition. The high prevalence of hrHPV other than 16 and 18 support the use of a 9-valent vaccine.

High rate of rubella seronegativity in perinatally-infected HIV women of childbearing age: A case-control study.

Rubella infection is a vaccine preventable disease. Maternal infection during pregnancy may lead to congenital infection and severe foetal malformations. Thanks to antiretroviral therapy, perinatally HIV-infected women have better prognosis and are now experiencing pregnancy. We evaluated the rate of rubella seronegativity in a cohort of HIV perinatally-infected women of childbearing age. A high rate of seronegativity was found in this group as compared to age-matched non-perinatally infected HIV-infected women (34.5% vs 6.90%, p < 0.01). MMR administration before rubella testing was identified in 75.8% of perinatally-infected women (22/29) with a mean of 2 doses (range: 1-3 doses). HIV perinatally-infected women of childbearing age should be screened repeatedly for rubella immunity.

Initiation of Antiretroviral Therapy Before Pregnancy Reduces the Risk of Infection-related Hospitalization in Human Immunodeficiency Virus-exposed Uninfected Infants Born in a High-income Country.

BACKGROUND: Epidemiological studies conducted in low- and high-income countries showed that infants exposed to maternal human immunodeficiency virus (HIV) have a high risk of severe infections. Immune alterations during fetal life have been proposed as a possible mechanism. METHODS: This prospective study assessed the relative risk of hospitalization for infection in HIV-exposed uninfected (HEU) infants as compared to HIV-unexposed (HU) infants born in a high-income country (HIC). Markers of monocyte activation and levels of pathogen-specific antibodies were measured at birth to identify correlates of infant susceptibility. RESULTS: There were 27 of 132 HEU infants and 14 of 123 HU infants hospitalized for infection during the first year of life (adjusted hazard ratio [aHR] 2.33, 95% confidence interval [CI] 1.10-4.97). Most of this increased risk was associated with the time of initiation of maternal antiretroviral therapy (ART). As compared to HU infants, the risk of hospitalization for infection of HEU infants was 4-fold higher when mothers initiated ART during pregnancy (aHR 3.84, 95% CI 1.69-8.71) and was not significantly increased when ART was initiated before pregnancy (aHR 1.42, 95% CI 0.58-3.48). The activation of newborn monocytes and the reduced transfer of maternal antibodies were most intense following ART initiation during pregnancy, and predicted the risk of infant hospitalization. CONCLUSIONS: These observations indicate that initiation of maternal ART before pregnancy reduces the susceptibility of HEU infants born in a HIC to severe infections, and that this effect could be related to the prevention of immune alterations during fetal life.

Prevalence, Risk Factors, and Serotype Distribution of Group B Streptococcus Colonization in HIV-Infected Pregnant Women Living in Belgium: A Prospective Cohort Study.

BACKGROUND: Group B streptococcus (GBS) infection is a leading cause of severe neonatal infection. Maternal GBS carriage during pregnancy is the main risk factor for both early-onset and late-onset GBS disease. High incidence of GBS infection has been reported in HIV-exposed but -uninfected infants (HEU). We aimed to determine the prevalence, characteristics, and risk factors for GBS colonization in HIV-infected and HIV-uninfected pregnant women living in Belgium. METHODS: Between January 1, 2011, and December 31, 2013, HIV-infected (n = 125) and -uninfected (n = 120) pregnant women had recto-vaginal swabs at 35-37 weeks of gestation and at delivery for GBS detection. Demographic, obstetrical, and HIV infection-related data were prospectively collected. GBS capsular serotyping was performed on a limited number of samples (33 from HIV-infected and 16 from HIV-uninfected pregnant women). RESULTS: There was no significant difference in the GBS colonization rate between HIV-infected and -uninfected pregnant women (29.6% vs 24.2%, respectively). HIV-infected women were more frequently colonized by serotype III (36.4% vs 12.5%), and the majority of serotype III strains belonged to the hypervirulent clone ST-17. Exclusively trivalent vaccine serotypes (Ia, Ib, and III) were found in 57.6% and 75% of HIV-infected and -uninfected women, respectively, whereas the hexavalent vaccine serotypes (Ia, Ib, II, III, IV, and V) were found in 97% and 100%, respectively. CONCLUSIONS: HIV-infected and -uninfected pregnant women living in Belgium have a similar GBS colonization rate. A trend to a higher colonization rate with serotype III was found in HIV-infected women, and those serotype III strains belong predominantly to the hypervirulent clone ST17.

High-risk human papillomavirus genotypes distribution in a cohort of HIV-positive women living in Europe: epidemiological implication for vaccination against human papillomavirus.

BACKGROUND: Worldwide, human papillomavirus (HPV) 16 and 18 represents 70% of high-risk (HR) HPV found in cervical cancer. However HIV-positive women are more frequently infected by HRHPV other than HPV 16 or 18 (OHR). We aimed to analyse the HRHPV genotype distribution in a cohort of HIV-positive women and to estimate the potential protection offered by the different HPV vaccines. METHODS: HRHPV genotypes by PCR and cytology were assessed in cervical samples from 508 HIV-positive women prospectively followed in Brussels. RESULTS: Women characteristics were as follows: African origin (84%), median age 42 years, median CD4 T 555/µl, 89% under combined antiretroviral therapy and 73% with HIVRNA less than 20 copies/ml. HRHPV prevalence was 23% (116/508): 38% had abnormal cytology, 76% carried OHR without HPV 16 or 18 and 11% had concomitant infection by OHR and HPV 16 or 18. The most frequent HRHPV were HPV52 (19.8%), HPV18 (14.6%), HPV31/35/51/58 (12.1% each), HPV56 (9.9%) and HPV16 (9.5%). Less than 30% of women had their HRHPV genotypes included in the bivalent or quadrivalent vaccines against HRHPV 16 and 18; however, 79% had their HRHPV covered by the ninevalent vaccine against HRHPV 16/18/31/33/45/52/58. CONCLUSION: The HRHPV genotypes distribution found in these women living in Europe with a successfully treated HIV is similar to the one found in Central Africa with HRHPV other than HPV16 or 18 retrieved in 87%. In this population, the bivalent or quadrivalent vaccines could offer protection in only 30% of women; however this protection could be extended up to 80% with the ninevalent vaccine.

Severe Infections in HIV-Exposed Uninfected Infants Born in a European Country.

BACKGROUND: Several studies indicate that HIV-exposed uninfected (HEU) children have a high infectious morbidity. We previously reported an increased incidence of group B streptococcus (GBS) infections in HEU infants born in Belgium. METHODS: This study was undertaken to evaluate the incidence and risk factors of all cause severe infections in HEU infants born in Belgium between 1985 and 2006, including the pre-antiretroviral (ARV) prophylaxis era (1985 to 1994). The medical charts of 537 HEU infants followed in a single center were reviewed. RESULTS: The incidence rate of severe infections during the first year of life was 16.8/100 HEU infant-years. The rates of invasive S. pneumoniae (0.62/100 infant-years) and GBS infections (1.05/100 infant-years) were, respectively, 4 and 13-fold higher in HEU infants than in the general infant population. Preterm birth was a risk factor for severe infections in the neonatal period (aOR = 21.34, 95%CI:7.12-63.93) and post-neonatal period (aHR = 3.00, 95%CI:1.53-5.88). As compared to the pre-ARV prophylaxis era, infants born in the ARV prophylaxis era (i.e., after April 1994) had a greater risk of severe infections (aHR = 2.93; 95%CI:1.07-8.05). This risk excess was present in those who received ARV prophylaxis (aHR 2.01, 95%CI 0.72-5.65) and also in those born in the ARV prophylaxis era who did not benefit from ARV prophylaxis as a result of poor access to antenatal care or lack of compliance (aHR 3.06, 95%CI 0.88-10.66). CONCLUSIONS: In HEU infants born in an industrialized country, preterm birth and being born during the ARV prophylaxis era were risk factors of severe infections throughout the first year of life. These observations have important implications for the clinical management of HIV-infected mothers and their infants.

Sustained viral suppression and higher CD4+ T-cell count reduces the risk of persistent cervical high-risk human papillomavirus infection in HIV-positive women.

BACKGROUND: Studies analyzing the impact of combination antiretroviral therapy (cART) on cervical infection with high-risk human papillomavirus (HR-HPV) have generated conflicting results. We assessed the long-term impact of cART on persistent cervical HR-HPV infection in a very large cohort of 652 women who underwent follow-up of HIV infection for a median duration of 104 months. METHODS: Prospective cohort of HIV-infected women undergoing HIV infection follow-up who had HR-HPV screening and cytology by Papanicolaou smear performed yearly between 2002 and 2011. RESULTS: At baseline, the median age was 38 years, the race/ethnic origin was sub-Sarahan Africa for 84%, the median CD4(+) T-cell count was 426 cells/µL, 79% were receiving cART, and the HR-HPV prevalence was 43%. The median interval of having had an HIV load of <50 copies/mL was 40.6 months at the time of a HR-HPV-negative test result, compared with 17 months at the time of a HR-HPV-positive test result (P < .0001, by univariate analysis). The median interval of having had a CD4(+) T-cell count of >500 cells/µL was 18.4 months at the time of a HR-HPV-negative test result, compared with 4.45 months at the time of a HR-HPV-positive test result (P < .0001). In multivariate analysis, having had an HIV load of <50 copies/mL for >40 months (odds ratio [OR], 0.81; 95% confidence interval [CI], .76-.86; P < .0001) and having had a CD4(+) T-cell count of >500 cells/µL for >18 months (OR, 0.88; 95% CI, .82-.94; P = .0002) were associated with a significantly decreased risk of HR-HPV infection. CONCLUSION: Sustained HIV suppression for >40 months and a sustained CD4(+) T-cell count of >500 cells/µL for >18 months are independently and significantly associated with a decreased risk of persistent cervical HR-HPV infection.

High-risk human papillomavirus infection in HIV-positive African women living in Europe.

INTRODUCTION: Cervical infection with high-risk human papillomavirus (HRHPV) induces cervical cancer and is present in 14% of women in Europe. We assessed the prevalence and incidence of cervical HRHPV in a cohort of HIV-positive women living in Belgium. METHODS: Prospective observational program of screening and follow up of HRHPV cervical infection performed by Hybrid Capture in 825 HIV-positive women between 2002 and 2011. Women without normal cervix at baseline were excluded. RESULTS: The final analysis included 652 women: median age 38 years, African origin (81%), median HIV follow-up (66 months), median CD4 count (426 cells/µL) and 79% on antiretroviral therapy (cART). At baseline, HRHPV prevalence was 43% and decreased significantly as both age and CD4 cell count increased: highest prevalence (100%) in women <30 years and <200 CD4/µL and lowest (19%) in women >40 years and >500 CD4/µL (p<0.0001, multivariate analysis). The relative risk (RR) to carry HRHPV at baseline decreases proportionally by 11% for each 5 years-age increase and by 11% for each 100 CD4 cells/µL rise (RR=0.89, 95% CI: 0.85-0.93; p<0.0001, Poisson regression for both). During follow-up, incidence rate of HRHPV was 13.4 per 100 women-years. CONCLUSION: We found a high HRHPV prevalence of 43% and an incidence rate of 13 per 100 women-years in this cohort of HIV-positive women living in Europe and on cART. Women under 40 years-age had the highest prevalence even with CD4 count >350 cells/µL. The magnitude of HRHPV epidemiology should prompt to evaluate the clinical efficacy of vaccines against HPV in HIV-infected women.

An audit about labour induction, using prostaglandin, in women with a scarred uterus.

OBJECTIVES: Induction of labour after a previous caesarean section is still controversial. We aim to analyse, in a population of women who have a uterine scar, the maternal, foetal and neonatal complications in relation to the mode of labour and delivery. STUDY DESIGN: Retrospective analysis of collected data from all the singleton deliveries of patients with a scarred uterus (N=798), admitted to the hospital between August 2006 and March 2009. OUTCOMES: maternal and perinatal complications. RESULTS: Among 798 singleton deliveries, 36.1% had a spontaneous labour, 12.6% a prostaglandin-induced labour and 2.9% an ocytocin-induced labour, and 48.4% had an elective caesarean section. The chance of delivering vaginally was respectively 84.4% for those who had a spontaneous labour, 75.2% for those who were induced using prostaglandin, 82.6% after induction using ocytocin. There were eight uterine ruptures, four after spontaneous labour (1.4%), two after prostaglandin induction (2%) and two at the time of an iterative caesarean section (0.5%). There were no differences between groups, except the risk of haemorrhage (17.4% after spontaneously induced labour, 34.8% after ocytocin, 17.8% after prostaglandin and 44.6% after iterative caesarean section; p<0.005) and the neonatal admissions when analysed by intention to treat only (8.3% after spontaneously induced labour, 9.1% after ocytocin, 12% after prostaglandin and 16.8% after iterative caesarean section; p<0.009). CONCLUSION: Although no increase in maternal or perinatal outcome was observed in relation to prostaglandin-induced labour after caesarean section, this study is too underpowered to exclude an increased risk.

High incidence of invasive group B streptococcal infections in HIV-exposed uninfected infants.

OBJECTIVES: The occurrence of an unusual number of group B streptococcal (GBS) infections in HIV-exposed uninfected (HEU) infants who were followed in our center prompted this study. The objective of this study was to describe and compare the incidence and clinical presentation of GBS infections in infants who were born to HIV-infected and -uninfected mothers. METHODS: All cases of invasive GBS infections in infants who were born between 2001 and 2008 were identified from the database of HEU infants and from the microbiology laboratory records. The medical charts of all infants with GBS infection were reviewed. RESULTS: GBS invasive infections were described for 5 (1.55%) infants who were born to 322 HIV-infected mothers who delivered in our center. The incidence of GBS infections during the same period was 16 (0.08%) of 20 158 infants who were born to HIV-uninfected mothers. One HEU infant presented a recurrent infection 28 days after completion of treatment for the first episode. Late-onset infection was more frequent in HEU infants (5 of 6 vs 2 of 16 episodes in the control population). The diseases were also more severe in HEU infants with 5 of 6 sepsis or sepsis shock in HEU infants versus 10 of 16 in control subjects, and most HEU infants had leukopenia at onset of infection. CONCLUSIONS: The incidence of GBS infection was significantly higher in HEU infants than in infants who were born to HIV-uninfected mothers. These episodes of GBS sepsis in HEU infants were mostly of late onset and more severe than in the control population, suggesting an increased susceptibility of HEU infants to GBS infection.

Topiramate improves neurovascular function, epidermal nerve fiber morphology, and metabolism in patients with type 2 diabetes mellitus.

PURPOSE: To assess the effects of topiramate on C-fiber function, nerve fiber morphology, and metabolism (including insulin sensitivity, obesity, and dyslipidemia) in type 2 diabetes. PATIENTS AND METHODS: We conducted an 18-week, open-label trial treating patients with topiramate. Twenty subjects with type 2 diabetes and neuropathy (61.5 ± 1.29 years; 15 male, 5 female) were enrolled and completed the trial. Neuropathy was evaluated by total neuropathy scores, nerve conduction studies, quantitative sensory tests, laser Doppler skin blood flow, and intraepidermal nerve fibers in skin biopsies. RESULTS: Topiramate treatment improved symptoms compatible with C-fiber dysfunction. Weight, blood pressure, and hemoglobin A(1c) also improved. Laser Doppler skin blood flow improved significantly after 12 weeks of treatment, but returned to baseline at 18 weeks. After 18 weeks of treatment there was a significant increase in intraepidermal nerve fiber length at the forearm, thigh, and proximal leg. Intraepidermal nerve fiber density was significantly increased by topiramate in the proximal leg. CONCLUSION: This study is the first to demonstrate that it is possible to induce skin intraepidermal nerve fiber regeneration accompanied by enhancement of neurovascular function, translating into improved symptoms as well as sensory nerve function. The simultaneous improvement of selective metabolic indices may play a role in this effect, but this remains to be determined.

Optimal management of HIV-infected women during pregnancy and delivery: an audit of compliance with recommendations.

BACKGROUND: The improvement in quality of life of HIV-infected patients and a reduced risk of vertical transmission have led to an increase in the desire for pregnancy among infected women. We assessed whether local recommendations were followed by HIV-infected mothers and their reasons for noncompliance. METHODS: Data on HIV-infected women who delivered between 2002 and 2006 in a large public university hospital in Brussels were collected and analyzed for compliance with recommendations and outcomes. RESULTS: The evidence suggests that current recommendations were followed in two thirds of the 203 recorded deliveries, as the patients in question (n = 140) came to term with an undetectable viral load and an uninfected newborn. About half of these women delivered vaginally, and 67% had ruptured membranes for less than 4 hours and required no instrumental delivery. Among those for whom optimal conditions for delivery were not met, two newborns were infected. CONCLUSIONS: The current recommendations were followed in only two thirds of the recorded deliveries. To improve results for the future, we have adapted our protocol both by starting antiviral therapy earlier and by assigning nurses to the patients' follow-up to try to promote better compliance to treatment during pregnancy.

Vertical transmission of HIV in Belgium: a 1986-2002 retrospective analysis.

Prophylactic interventions have lead to the reduction of the mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) to less than 2% in industrialized countries. The aim of this study was to evaluate the changes over time in vertical transmission according to the standard care of prophylaxis in the practice of a single large reference center and to identify the risk factors for failure. The rate of MTCT decreased progressively from 10% in 1986-1993 to 4.7% in 1999-2002, reflecting the progressive implementation of newly available means of prevention. During the last period evaluated (1999-2002), where highly active antiretroviral therapy (HAART) prophylaxis was the standard of care, 17% of women had a viral load between 400 and 20,000 copies/ml around delivery and 5% had a viral load above 20,000 copies/ml. High viral load and low CD4 lymphocyte count were strongly associated with vertical transmission. The rate of MTCT in women who received HAART for more than one month during pregnancy was 1.7%, compared to 13.3% in women treated with HAART for less than one month. The risk of vertical transmission in the absence of therapy was four times higher than before the era of antiretroviral therapy (ART; p=0.05). In conclusion, since the prevention of MTCT of HIV with HAART is the standard of care, a short duration or absence of ART during pregnancy linked to late or absent prenatal care is associated with a high risk of transmission. The early detection of HIV-1 infection in pregnant women, and close follow up and support during pregnancy are crucial to the success of the prevention of transmission.

Is screening for fetal anomalies reliable in HIV-infected pregnant women? A multicentre study.

OBJECTIVE: To assess the impact of HIV infection on the reliability of the first-trimester screening for Down syndrome, using free beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A and fetal nuchal translucency, and of the second-trimester screening for neural tube defects, using alpha-fetoprotein. PATIENTS AND METHODS: Multicentre study comparing the multiples of the median of markers for Down syndrome and neural tube defect screening among 214 HIV-infected pregnant women and 856 HIV-negative controls undergoing a first-trimester Down syndrome screening test, and 209 HIV-positive women and 836 HIV-negative controls with a risk evaluation for neural tube defect. The influence of treatment, chronic hepatitis and HIV disease characteristics were also evaluated. RESULTS: Multiples of the median medians for pregnancy-associated plasma protein-A and beta-human chorionic gonadotrophin were lower in HIV-positive women than controls (0.88 vs. 1.05 and 0.84 vs. 1.09, respectively; P < 0.005), but these differences had no impact on risk estimation; no differences were observed for the other markers. No association was found between HIV disease characteristics, antiretroviral treatment use at the time of screening or chronic hepatitis and marker levels. CONCLUSION: Screening for Down syndrome during the first trimester and for neural tube defect during the second trimester is accurate for HIV-infected women and should be offered, similar to HIV-negative women.